APPLICATION FOR CLIINICAL PROFESSIONAL COUNSELOR ... - …

1 BRIAN SANDOVAL nevada STATE board OF EXAMINERS FOR PO Box 370130 Governor MARRIAGE & FAMILY THERAPISTS AND Las Vegas, nevada 89137 CLINICAL PROFESSIONAL COUNSELORS Office: (702) 486-7388 Quinn Kennedy Fax (702) 486-7258 Interim Executive Director 1 Updated 7/16 APPLICATION FOR CLIINICAL PROFESSIONAL COUNSELOR LICENSURE APPLICATION Fee: $ check or money order made payable to: NV State board of Examiners MFT & CPC I. APPLICANT IDENTIFICATION INFORMATION: Internship Licensure Interim Permit 1. Last Name First Name Middle Name (Maiden) Other Names or AKA 2. Home Address City State Zip Social Security 3. Home Phone Number Cell Phone Number Email Address Date of Birth 4. Primary Employer Name of Supervisor Business Telephone/Ext. 5. Business Address: Street/ Box/ Suite City State Zip Preferred Mailing Address: Home Office Other Your preferred mailing address may be public information and may be placed on the board s website and/or made available to outside organizations.

2 If you do not want your home or work address available to the public, please provide an alternate mailing address:__ _____ NAME or ADDRESS CHANGE: It is the applicant's responsibility to notify the board in writing of any name or address change that might occur during the APPLICATION process and licensure PLEASE KEEP A COPY OF ALL RECORDS FOR YOUR FILE. NAC 641A gives the board the right to refuse to issue, suspend or revoke any registration, permit or license, of any licensee or applicant if the candidate secures the license, registration or permit by fraud, deceit or misrepresentation on any APPLICATION for licensure submitted to the board . Please review NRS 641A and NAC 641A from the website at the About Us page. Disclosure of your social security number is mandatory pursuant to 42 666(a)(13) and will be used for tax enforcement purposes, may be used for child support enforcement purposes or may be provided to a licensing or examination entity which uses a national examination for purposes of verification of license or examination status.

3 II. GENERAL INFORMATION: 1. Are you a citizen of the United states ? Yes No 2. Are you lawfully entitled to remain in the Yes No Alien Registration Number: 3. Have you ever filed any APPLICATION for licensure or registration in nevada ? Yes No If yes, please answer the following: a. Which Credential: When: Under what name: State/License Number: b. Which Credential: When: Under what name: State/License Number: 4. Do you currently hold or have you ever held a license certificate or registration to practice clinical PROFESSIONAL counseling in another state or jurisdiction? Yes No If yes, please answer the following: a. Which Credential: When: Under what name: State/License Number: b. Which Credential: When: Under what name: State/License Number: 5.

4 What is your qualifying Graduate Degree? Degree Credits: 6. Name of the School, College, University or Institution: nevada State board of Examiners MFT & CPC CPC APPLICATION Page 2 2 III. EXAMINATION: 1. If you have not previously taken the National Clinical Mental Health Counseling Examination developed by the National board for Certified Counselors (NBCC) and achieved a passing score, you will be notified in writing if you are eligible to register and sit for the examination. Applicants must first satisfy the nevada State educational requirements in order to be authorized by the board to register for the examination. 2. Did you complete the National Clinical Mental Health Counseling Examination through the nevada State board office? Yes No If answered no , please provide the following: Name of the state other than nevada in which you took the National Clinical Mental Health Counseling Examination (Contact NBCC to have a copy of your Official score sent directly to the nevada board office).

5 Date exam was taken: Location/State of Exam: IV. BACKGROUND INFORMATION 1. Have you ever been arrested, charged with, or convicted of, or plead guilty or nolo contendere to any offense or violation of any federal, state or local law, including any foreign country, which is a misdemeanor, gross misdemeanor, or felony, excluding any minor traffic offense? Please note driving or being in control of a motor vehicle while under the influence of any chemical substance, including alcohol, is not considered a minor traffic offense. Yes No 2. Have you ever had a complaint filed with a certifying, licensing, or registering body or any PROFESSIONAL association against you for alleged unethical behavior or unprofessional conduct? Yes No 3. Have you ever been censured or had any disciplinary action taken against you for unethical behavior, unprofessional conduct or any other grounds by any certification or licensing board or other agency, institution, or PROFESSIONAL organization?

6 Yes No 4. Have you ever been investigated, charged with, or convicted of unprofessional conduct, negligence, or PROFESSIONAL incompetence by any certification or licensing board or other agency, institution, or PROFESSIONAL organization? Yes No 5. Have you used any alcohol, narcotic, barbiturate other drug affecting the central nervous system, or other drug which may cause physical or psychological dependence, either to which you were addicted or upon which you were dependent within the last 5 years? Yes No 6. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? Yes No 7. Have you used controlled substances which were obtained illegally or which were not obtained pursuant to a valid prescription order or which were not taken following the direction of a licensed health care provider within the past 5 years?

7 Yes No 8. Has any state, jurisdiction, province, or PROFESSIONAL organization denied your APPLICATION for credentials or PROFESSIONAL membership? Yes No 9. Have you ever been named as a defendant or have been requested to respond as a defendant to a legal action involving PROFESSIONAL liability (malpractice) or had a PROFESSIONAL liability claim paid in your behalf or paid such a claim yourself? Yes No IF ANY OF THE ABOVE QUESTIONS HAVE BEEN ANSWERED "Yes," please explain circumstances and outcome on the reverse side. V. ACADEMIC REQUIREMENTS: A. I am submitting official transcripts verifying having met the academic requirements as indicated (select one by initialing the appropriate line.) A graduate degree in mental health counseling or community counseling from a program accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) An acceptable graduate degree as determined by the board which includes completion of a practicum and internship in mental health counseling which was taken concurrently with the degree program and was supervised by a licensed mental health PROFESSIONAL as described in NRS 641A.

8 nevada State board of Examiners MFT & CPC CPC APPLICATION Page 3 3 Please print or type clearly giving an accurate record of your educational preparation below. YOU MUST COMPLETE ALL INFORMATION FOR ALL SCHOOLS/COLLEGES/UNIVERSITIES/INSTITUTIO NS ATTENDED AND DEGREES RECEIVED OR YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE. (You may attach additional sheets, if necessary.) B. Undergraduate Education: Name of School Address City State Zip Title of Degree (in the original language Date Awarded Major Attendance From To C. Graduate Education in Marriage and Family Therapy: Name of School Address City State Zip Title of Degree (in the original language Date Awarded Major Attendance From To D.))

9 Other Graduate Study: Name of School Address City State Zip Title of Degree (in the original language Date Awarded Major Attendance From To E. Required Areas of Study: 1. Human Development, Including issues of Sexuality: (minimum 1 course; 3 semester hours or 4 quarter hours) Course Title (as it appears on Transcript) Course Number: Credit Hours: 2. Individual Counseling Theories: (minimum 1 courses; 3 semester hours or 4 quarter hours) Course Title (as it appears on Transcript) Course Number: Credit Hours: 3. Individual Counseling Techniques and Practices: (minimum 1 courses; 3 semester hours or 14 quarter hours) Course Title (as it appears on Transcript) Course Number: Credit Hours: 4.)

10 Lifestyle and Career Development: (minimum 1 course; 3 semester hours or 4 quarter hours) Course Title (as it appears on Transcript) Course Number: Credit Hours: 5. Group Dynamics Counseling and Consulting: (minimum 1 course; 3semester hours or 4 quarter hours) Course Title (as it appears on Transcript) Course Number: Credit Hours: nevada State board of Examiners MFT & CPC CPC APPLICATION Page 4 4 6. Ethics and PROFESSIONAL Studies: (minimum 1 course; 3 semester hours or 4 quarter hours) Course Title (as it appears on Transcript) Course Number: Credit Hours: 7. Supervised Clinical Practice in CPC: (minimum 3 courses; 9 semester hours or 12 quarter hours) (over 1 calendar year) Course Title (as it appears on Transcript) Course Number: Credit Hours: 8.